Bipolar Disorder and Sleep
Everyone has good days and bad days, and it’s natural to experience a range of emotional ups and downs. In bipolar disorder, though, moods exceed this normal range as people have periods of extreme highs (mania) and lows (depression). In the past, bipolar disorder was called manic-depressive disorder as a way of referring to a person’s moving between these two states.
Bipolar disorder is estimated to affect about 4.4% of people over the course of their lives, and this condition has significant effects on a person’s well-being. Previous research has indicated that 82% of people with bipolar disorder described having serious impairment within the past year.
Sleep has a well-established connection with bipolar disorder. During manic periods, people tend to sleep much less than normal, and during depressive periods, they tend to sleep much more. In each state, these sleep changes can amplify the symptoms of the condition.
Studies have increasingly found that sleep problems can be a predictor of bipolar episodes. Improving sleep for people with this condition may help manage symptoms and reduce the frequency of mania or depression.
In this comprehensive guide to bipolar disorder and sleep, we’ll review the basics about bipolar disorder including its types, symptoms, diagnosis, and treatment. The guide investigates the complex connection between bipolar disorder and sleep and identifies ways that people with this condition can improve sleep, and in so doing, improve their mental health as well.
What is Bipolar Disorder?
Bipolar disorder is a type of mental health condition known as a mood disorder. Mood disorders include several conditions in which a person has identifiable emotional disturbances. What distinguishes bipolar disorder from other types of mood disorders is that patients experience both extreme highs and lows.
People with bipolar disorder are not always either manic or depressed. There are times when the condition is in remission, during which a person is mostly or completely free of symptoms.
What Are the Symptoms of Bipolar Disorder?
The symptoms of bipolar disorder are different depending on whether a person is in a manic or in a depressed state.
What Are the Symptoms of Bipolar Disorder During Manic Episodes?
During manic periods, people may feel extremely energetic, enthusiastic, and happy. They may have racing thoughts, quickened speech, and high levels of activity. People feel less need for sleep during episodes of mania, and they can be easily distracted. Even though they may feel elation, they can be irritable and impatient with others.
Mania brings an elevated risk of engaging in high-risk behaviors, especially because people experiencing mania usually do not realize that they are in this mental state. This lack of recognition can also lead to conflict with others and problems in social relationships.
The diagnostic definition of mania involves a person having symptoms for one week or longer. According to these criteria, mania includes elevated or irritable mood, increased energy, and three or more of the other types of symptoms described above.
Hypomania is a state that falls short of full-fledged mania. In a hypomanic episode, a person’s symptoms are less severe and often do not last for as long -- a minimum of four days as opposed to one week for mania.
Hypomania includes feelings of energy, happiness, and creativity. In fact, many people find a hypomanic period to be enjoyable, productive, and with little impact on overall functioning. That said, they can still be easily distracted and irritable in ways that can create interpersonal conflict.
Manic psychosis is an especially intense episode of mania. It can involve hallucinations, delusions of grandeur, paranoid delusions, and extreme increases in activity levels. Manic psychosis can resemble schizophrenia. This state can devolve to delirious mania in which a person’s speech and actions are highly unpredictable and irrational. Hospitalization is usually required during manic psychosis.
What Are the Symptoms of Bipolar Disorder During Depressed Episodes?
Depressed episodes stand in stark contrast to manic ones. Depression in bipolar disorder has symptoms that are similar to unipolar depression (depression in people who do not experience mania).
These symptoms include reduced energy, worsened mood, sadness, lack of interest in activities that normally bring pleasure, feelings of worthlessness or hopelessness, appetite changes (including both eating more or eating less), sleep changes (including sleeping too much or too too little), social isolation, difficulty concentrating, excess guilt, indecisiveness, and thoughts of suicide.
Psychosis, in which a person loses touch with reality, including with possible hallucinations or delusions, can occur during a state of depression. This is more common in patients with bipolar disorder than in people with unipolar depression.
A depressive episode is formally diagnosed as such when a person has five or more of these symptoms, one of which must be depressed mood or loss of interest, during a two-week period.
Can Someone Have Mania and Depression at the Same Time?
Yes, and this type of episode is referred to as having mixed features. If a person has mania or hypomania along with three or more symptoms of depression, it can be categorized as a mixed episode. For example, a person may feel sad but also highly energized. Mixed episodes can be especially dangerous because the risk of suicide is elevated during these periods.
Most of the time, though, patients do not have mixed episodes. Instead, they may move between periods of mania and depression. The frequency of these episodes varies based on the person and can range from multiple episodes in a year to multiple episodes during a person’s entire life. If a person has four or more episodes within a year, it is called rapid cycling.
What Are the Health Consequences of Bipolar Disorder?
Bipolar disorder can have significant health consequences. During depressed episodes, patients suffer from major disturbances in mood and quality of life that can reduce functioning in all aspects of life. In manic episodes, risky behaviors can cause severe negative repercussions, and irritability may harm relationships with friends and family.
People with bipolar disorder are at a much higher risk of attempting or committing suicide. Studies estimate that the incidence of suicide is 15 times higher in people with bipolar disorder than in the general public.
Rates of substance abuse are higher in people with bipolar disorder. Other mental health conditions, like anxiety and ADHD, frequently occur alongside bipolar disorder. People with bipolar disorder are also at a higher risk of cardiovascular problems.
For all of these reasons, bipolar disorder is considered to be one of the top 10 leading causes of disability worldwide.
What Are the Types of Bipolar Disorder?
Bipolar disorder is classified into different types based on how a patient experiences the symptoms of the condition.
Bipolar I Disorder involves significant manic episodes that usually require hospitalization. Extended depressive episodes are also frequent, and some patients may have mixed episodes.
Bipolar II Disorder involves depression and hypomania but without more severe periods of mania.
Cyclothymic Disorder occurs over an extended period of time -- two years or more -- and includes various symptoms of depression and hypomania. While a patient with Cyclothymic Disorder has symptoms reflective of bipolar disorder, they do not meet the condition’s formal diagnostic criteria.
There is also a category, known as Other Specified and Unspecified Bipolar and Related Disorders, that is used to group together the remaining types of bipolar disorder that do not fit the definitions of Bipolar I, Bipolar II, or Cyclothymic Disorder.
The type of bipolar disorder that a person has can affect their treatment as well as their overall prognosis.
How is Bipolar Disorder Diagnosed?
A doctor or psychiatrist diagnoses bipolar disorder based on specific criteria that have to do with the type and severity of symptoms. There is no laboratory test that can diagnose bipolar disorder.
Diagnosis usually involves two steps. The first step involves an evaluation of the patient’s condition and history including a discussion of any symptoms they may have experienced. A patient’s friends and family may be involved in this process, especially for answering questions about possible manic episodes.
If this first step indicates that a patient likely has bipolar disorder, then the second step is to make sure that the symptoms are not being caused by any other condition. This can include a review of a patient’s prescription medications as well as blood tests, urinalysis, and checking thyroid function.
How is Bipolar Disorder Different From Depression?
Both bipolar disorder and depression are mood disorders. People with bipolar disorder experience symptoms of depression, but they also have episodes of mania or hypomania. People with unipolar depression do not have manic episodes.
Part of the diagnostic process is intended to determine if a patient has had symptoms of mania so that bipolar disorder can be differentiated from unipolar depression.
What Are the Causes of Bipolar Disorder?
There is no known cause of bipolar disorder. Many researchers believe it is related to brain chemistry, but there is no established scientific finding that identifies the exact elements of brain function that give rise to bipolar disorder.
There are some indications that genetics play a role in bipolar disorder, but the disease is not considered to be determined strictly by genes. A family history, such as having a parent or sibling with the condition, increases a person’s risk, but most people with a family history never develop bipolar disorder.
Similarly, there is no exact cause for what triggers manic or depressive episodes in people who have already been diagnosed with bipolar disorder. Studies indicate that the risk of mania in people with bipolar disorder is heightened after childbirth (in women), when a person has insomnia, or when a person is using certain types of recreational or prescription drugs.
What are the Treatments for Bipolar Disorder?
Treatment for bipolar disorder usually includes medications to manage symptoms and often involves psychotherapy. Electroconvulsive therapy, also known as ECT or shock therapy, can be used when other treatments do not help. The exact therapy provided depends in large part on the type and severity of a patient’s symptoms.
If a person is in a more extreme state, including psychosis associated with mania or depression, they may be hospitalized in order to reduce the risk of harming themselves or others.
Most patients with bipolar disorder take medications as part of their treatment. The most common classes of drugs that are used include mood stabilizers, antidepressants, and antipsychotics. Doctors work to tailor pharmacotherapy to fit a patient’s state and symptoms. It is important for patients to take medications as prescribed and not to stop taking them without consulting with a doctor as this can cause a rebound in symptoms.
For patients with extreme depression that does not get better with medications, or if a patient cannot tolerate the side effects of medications, ECT can be an effective treatment. During ECT, a patient receives anesthesia and then has an electric current applied to the brain. ECT often brings rapid relief to potentially life-threatening depression. While most often used for episodes of depression, it may also be useful in treating mania.
Psychotherapy, also known as talk therapy, can be another useful component of treatment for bipolar disorder. It is often employed as a type of maintenance therapy once a patient’s more significant symptoms have been reduced or resolved. Cognitive behavioral therapy (CBT) works to confront negative thinking and often helps patients with bipolar disorder. Other types of talk therapy include Interpersonal and Social Rhythm Therapy (IPSRT), which works to regulate daily routines, psychoeducation, which helps patients understand, monitor, and manage their mental health, and family or group counseling.
What is the Relationship Between Bipolar Disorder and Sleep?
Bipolar disorder and sleep have a multifaceted relationship. Changes to sleep patterns are extremely common for people with bipolar disorder and can include both insomnia and hypersomnia. In addition, mounting evidence points to sleep disturbances as being a contributing factor that can worsen symptoms of bipolar disorder or cause it to recur after a period of remission.
The following sections explain in further detail the way that bipolar disorder impacts sleep and how sleep problems influence the condition’s development.
How Does Bipolar Disorder Impact Sleep?
Disturbed or altered sleep is common in patients with bipolar disorder. Changes to sleep patterns can occur during both manic and depressed episodes.
During manic episodes, people with bipolar disorder feel a dramatic reduction in the need to sleep. With enhanced energy and mood, somewhere between 69% and 99% of patients in manic episodes indicate that they feel a decreased need for sleep.
When depressed, patients with bipolar disorder frequently sleep too much (hypersomnia). This can relate to a lack of energy and decreased interest in normally enjoyable activities, both of which are common depression symptoms. Hypersomnia is estimated to affect 38% to 78% of bipolar patients. Insomnia can also happen during episodes of depression, and in general, sleep can become disordered and inconsistent.
Even during periods of remission, when a person is not in a manic or depressed condition, sleep disturbances are common. One study found that 70% of people with bipolar disorder still have significant sleep disturbances during this period.
Sleeping problems are not just limited to too much or too little sleep. People with bipolar disorder frequently have low-quality sleep, inconsistency in their sleep from one night to the next, and problems getting to sleep. The nature of a person’s sleeping difficulties can shift significantly with time, the patient’s mood, and their response to medications.
A possible underlying cause for sleep disruptions in people with bipolar disorder is a disordered circadian rhythm. The circadian rhythm is part of the body’s natural system for managing and balancing wakefulness and sleep. In most people, that rhythm is closely aligned with external cues, most specifically the day-night cycle in their local area. However, when the circadian rhythm gets thrown off, it can create a range of sleep disorders. Studies have found circadian rhythm irregularities in people with bipolar disorder, and these may be contributing to the diversity of sleeping problems that these patients can experience.
Another cause of sleep disruption is obstructive sleep apnea (OSA), a condition in which a person’s breathing stops temporarily at different points through the night. One study has found that nearly 25% of people with bipolar disorder have OSA, which can cause marked reductions in sleep quantity and quality. OSA has been linked to a host of other health problems as well, including depression and cardiovascular problems.
How Does Sleep Impact Bipolar Disorder?
Quality sleep is known to play a role in regulating mood, and that effect appears to be heightened in mood disorders. In multiple ways, poor sleep can lead to a worsening of bipolar disorder.
Numerous studies have found that sleeping problems, especially insomnia, play a role in bipolar disorder. This research has demonstrated that lack of sleep can exacerbate symptoms of both mania and depression. The impact has been found in studies examining patient reports over periods of seven days, eight weeks, and 12 months, indicating that sleep affects mood from the short through the long-term.
For patients who are in remission, sleep deprivation is associated with recurrence of symptoms. Research has found that sleep disturbances were the most frequent predictor of manic episodes and the sixth most common predictor of depressed episodes. Studies in which patients have been deprived of sleep have shown that this can induce mania or hypomania. Lack of sleep caused by sleep apnea may be a contributor to the recurrence of manic symptoms as well.
If poor sleep worsens bipolar disorder, the logical follow-up is to ask whether improving sleep can help reduce the symptoms. Early evidence indicates that a focus on sleep may have this potential. For example, one study that used a talk therapy intervention tailored for treating insomnia found that on average patients receiving this therapy got better sleep and were at a lower risk of relapse. Because of the way that sleep bolsters the ability to manage mood, a focus on sleep may serve as part of a valuable preventive mental health approach.
How Can People With Bipolar Disorder Improve Sleep?
Given the potential benefits of better sleep for people with bipolar disorder, a number of potential steps can be considered to foster more consistent, higher-quality sleep.
Get Immediate Help If Necessary
If you are having thoughts of suicide or self-harm, get immediate help before trying to focus on sleep. Call 1-800-273-8255 to reach a trained counselor at the National Suicide Prevention Lifeline. Calls are free and confidential, and the service is available 24/7/365. Crisis services are also available through the organization’s Lifeline Chat program.
Work With a Doctor or Health Professional
Because of the complexity of bipolar disorder and the various ways it can impact a person’s life, getting help from a health professional is the first step in any plan for treatment.
Working with a doctor or psychiatrist can make sure that plans to improve sleep work in concert with a patient’s medications. If other conditions like sleep apnea are interrupting sleep, a doctor can discuss potential treatments, including with positive airway pressure (PAP) devices.
When necessary, health professionals can offer referrals to specialists who can help with specific types of talk therapy or sleep improvement techniques.
Cognitive Behavioral Therapy for Insomnia for Bipolar Disorder
As discussed in the section on treatment, psychotherapy, also known as talk therapy, can be beneficial to people with bipolar disorder. It can empower patients to better understand and manage their thoughts, mood, and social relationships.
Some types of talk therapy have been adapted specifically to help with sleeping problems. An example is cognitive behavioral therapy for insomnia (CBT-I), which works to create healthier thinking and habits related to sleep.
Some counselors have taken CBT-I and made it even more specific by tailoring a treatment program especially for people with bipolar disorder. This version, known as CBTI-BP, was tested in a small study of nearly 60 patients and found to have positive outcomes for both sleep and management of bipolar disorder over a follow-up period of six months.
Experts routinely express that sleep hygiene is important for anyone who wants to get better sleep. Optimizing sleep hygiene includes ensuring that our habits and environment support, rather than detract from, quality sleep.
Many aspects of sleep hygiene are emphasized as part of CBT-I. There is overlap as well with components of other types of talk therapy, such as psychoeducation and IPSRT, that may be used in the context of bipolar disorder.
Specific steps to enhance sleep hygiene focus on our routines and sleep setting.
Routines and Habits
- Keep a regular schedule: having a set time to go to bed and wake up that you follow every day, even on weekends or holidays, can create a sense of consistency that facilitates regular sleep. One study in patients with bipolar disorder found that just setting this schedule helped make it easier to get to bed at night.
- Have stable routines before bed: a daily routine with the same steps before bed -- such as brushing your teeth, stretching, showering, etc. -- primes the mind and body for going to bed. This type of routine-building can fit in well with IPSRT psychotherapy for patients with bipolar disorder.
- Restrict activity in bed: to make sure that your bed is associated with sleep, avoid other activities like eating or watching TV while in bed. As much as possible, limit activities in bed to sleep and sex.
- Avoid alcohol and caffeine: alcohol can worsen mood problems for people with bipolar disorder and in general, has a negative effect on sleep. As a stimulant, caffeine can complicate attempts to get to sleep, especially if it is consumed later in the day.
- Incorporate physical activity into your day: finding time for regular physical activity is good for overall health and can help with sleep as well.
- Try out relaxation techniques: finding ways to calm the mind and body can lead to a smoother transition to sleep. A study in people with bipolar disorder found that mindfulness meditation was able to help with both sleep and mood regulation.
- Avoid blue light: devices like laptops, tablets, and mobile phones give off blue light that can create disruptions to the body’s production of melatonin. Limit use of these devices for a half-hour or more before bed, and if possible, don’t use them in the bedroom at all.
- Cultivate an inviting sleep surface: when you head to bed, you want it to be as easy as possible to fall asleep. That’s best accomplished by having a bed you love, including a high-performance mattress, great sheets, a supportive pillow, and cozy blankets.
- Find a comfortable temperature: the temperature that feels right can vary from person to person, but err toward a cooler bedroom as studies have pointed toward benefits of sleeping in a cool environment.
- Block out distractions: you want to keep excess light or noise from waking you up or bothering you when you’re trying to fall asleep. A white noise machine or earplugs may help with any problems that you have with noise. Extra-dark curtains or a sleep mask can be useful if your room receives lots of external light.
Light therapy attempts to help orient a person’s circadian rhythm by exposing them to a very bright light for a short period of time each day. It is most frequently used for treating a type of depression associated with the winter known as seasonal affective disorder (SAD).
People with bipolar disorder should consult with a doctor before attempting to use light therapy. While one study found that it can benefit patients, others have found that it can have significant negative effects on mood. The timing of light therapy in the day may play a role, but research studies to date have been small.
Given its potential negative effects for people with bipolar disorder, light therapy should be administered only when working closely with a health professional.
The body naturally produces melatonin, a hormone, as part of its system for managing the cycle of wakefulness and sleep. Melatonin is normally produced as daylight fades away, and it promotes a transition to nightly sleep.
Because melatonin can play a role in the circadian system, some people take supplements to improve sleep. One small study involving 11 patients found that it improved sleep duration in people with bipolar disorder.
While this study is promising, more research is needed to understand whether melatonin is a safe and effective way for people with bipolar disorder to get better sleep.
Patients with bipolar disorder should always talk with their doctor before taking melatonin or any other supplement or medication.
Learn More About Bipolar Disorder and Sleep
- National Suicide Prevention Lifeline (1-800-273-8255). This is a totally free and fully confidential service for people who are thinking about suicide or suffering from severe mental illness. Trained professionals are available 24/7/365.
- The Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline. Free support is offered through this phone service that can also assist with referrals to medical professionals and community resources. The service is available 24/7/365.
- Depression and Bipolar Support Alliance (DBSA). DBSA provides articles, resource guides, podcasts, and videos to help people learn about these conditions and find support both in-person and online.
- The National Alliance on Mental Illness (NAMI): Support. This page has tips for getting help for patients as well as friends and family of people with mental illness. NAMI’s national hotline can also be reached at 1-800-950-NAMI.
- Mood Network. The Mood Network is a free program to connect people with mood disorders. It includes support services and helps with information gathering to support research into the most effective treatments.
Adolescents and Young Adults
- National Institute of Mental Health (NIMH): Bipolar Disorder in Children and Teens. This guide from NIMH, part of the National Institutes of Health (NIH), provides information about bipolar disorder in the context of younger patients.
- American Academy of Adolescent and Childhood Psychiatry (AAACP): Resources for Family & Youth. AAACP is composed of youth counselors, and this page explains how young patients and family members can find professional help and other resources.
- Psychology Today: Cognitive Behavioral Treatment for Insomnia (CBT-I) Defined. CBT-I has shown promise in addressing many sleep difficulties, and the treatment is explained in this article by Allison Siebern, Ph.D., a sleep psychologist and Assistant Professor at Stanford.
- Osmosis: Bipolar Disorder. This nearly seven-minute video provides an easy-to-follow introduction to bipolar disorder and how it is different from depression.
- Mayo Clinic: Bipolar Disorder. In this video, Dr. Mark Frye, a psychiatrist at the Mayo Clinic, explains some of the diagnostic and treatment challenges associated with bipolar disorder.
- Stanford Health Care: Understanding Bipolar Disorder. This talk by Dr. Shefali Miller, a Clinical Assistant Professor at Stanford University Medical Center, is more medically technical and complex but provides an in-depth review of diagnosis, treatment, and ongoing research related to bipolar disorder.